- Email: [email protected]
Assessment of dynamic orthoses with the macreflex® locomotion analysis system in children with spastic diplegia and hemiplegia
Abstracts
measurements before casting (to: -4.8”, t 1: 9.9”, t2: 5.3”, t3: 2.5”). The peak ankle dorsiflexion during mid swing showed an increase (P c 0.001) for all measurements after cast removal as well (to: -10.8”, tl: 4-Y’, t2: 0.9”, t3: -2.9”). We observed an increase (P < 0.001) of ankle dorsiflexion at initial contact (to: -10.6”, tl: 1.8”, t2: -1.9”, t3: -3.2”). When there was a knee hyperextension during stance before casting (minimum knee flexion c 5’) the hyperextension was reduced (P < 0.05) for all measurements after cast removal (to: -5.7’, tl: 6.3”, t2: 0.5”, t3: -1.3’). The cadence was reduced from 145.9 steps/mm before therapy to 133.2 steps/mm six months after cast removal and the walking speed remained unchanged.
279
ward, but the typical gait pattern with an equinus of the foot and flexed knees and hips establishes. On this rationale a new orthosis with a spring function was developed. 10 patients were fitted with these ortheses. Their gait was studied once without any device, then with a conventional rigid type of functional orthosis and with the new spring type of functional orthosis. The results are presented. In summary the conventional orthosis inhibits the dropping of the foot, but leads to a short heel contact and impedes the rocking of the ankle, which is expressed in the force plate data. Walking with the spring type orthosis corrects the functional deformities most efliciously. Kinematics and force plate data are almost normalized.
Discussion
The increase of peak ankle dorsiflexion during stance and midswing results in a greater stability during stance and less problems with foot clearance during swing phase. The increased ankle dorsiflexion at initial contact indicates a better prepositioning of the foot for loading response. All the observed changes lead to the conclusion that short leg casting is a suitable medium-term method to improve the gait and to reduce the dynamic ankle plantarflexion. But with the observed loss of correction after 6 months this method can not be considered a successful long-term treatment. We believe that surgical corrections can be delayed by the use of this conservative treatment until the motor development is more advanced and the results of surgical corrections are more predictable. Moreover, casting is an inexpensive and repeatedly applicable method with only minor risks. Correction of typical gait pattern in spastic bemiplegic and diplegic patients using a functional spring-type orthis
R Brunner, G Me&r, Th Ruepp Motion Analysis Laboratory, Department of Pediatric Orthopaedics of the University of Basle, Children’s Hospital, CH-4005 Base], Switzerland In patients with spastic hemiplegia or diplegia a gait pattern with a functional drop foot is typical. The foot strikes the ground with the tip toes or just the planta pedis in an equinus position. During loading of the leg the body weight forces the heel down to the floor. The spastic triceps reflex is activated. The calf is pulled backwards while the center of gravity of the body moves forward, resulting in an hyperextension of the knee. The force of the triceps acts backwards, leads to a break of the acceleration during walking and is missing at the time when maximal acceleration occurs in normals. The energy for walking increases. These findings are documented by typical force plate- and VICON-data as well as by video-pictures. A way of compensation for the loss of muscle force is early knee and hip flexion. Thereby, the force of the triceps reflex is directed for-
Assessmentof dynamic ortboses with tbe macreflex” locomotion analysis system in children with spastic diplegia and bemiplegia
L van Wendt, S Jiintti, P Tornikoski, R Jaakkola, K Lehtonen Department of Pediatric Neurology, University of Helsinki and Children’s Castle Hospital, Helsinki, Finland Orthoses of numerous types are frequently prescribed for children with cerebral palsy in order to enhance ambulation, but the effects of these have rarely been assessed objectively [ 11. The aim of the present study was to evaluate the usefulness of the Macreflex locomotion analysis system for the registration of the effects of dynamic orthoses. This type of foot-ankle orthosis differs from more traditional ones by being made of flexible polypropylene and by the special supporting and correcting, individually moulded shape of plantar part of the orthosis [2]. The patients were all followed up at Children’s Castle in Helsinki and represented spastic diplegia (11) or hemiplegia (7), were >4 years (mean age 7.4 years), walked independently with or without crutches, and had used a uni- or bilateral dynamic orthosis >6 months. The recordings were made with and without orthoses using a single-camera (infrared), two-dimensional MacReflex equipment with seven reflecting markers attached to the patient. The analysis was confined to nine separate components based on ROM of hip, knee, and ankle joints; gait symmetry, cadence, and mean velocity. A clinically significant change was considered to be present whenever the gait components had changed ~20% and the other components > 5”. A total score was constructed as follows: 1 = improvement, 0 = no change, -1 = deterioration. ReNllts
All but 2 children performed better with their orthoses on, but a very evident favourable effect score (+8 or +9) was shown by only two infants. There was little effect on
280
Gait and Posture 1995; 3: No 4
the movement of the hip, whereas symmetry of gait and the ROM of the knee improved in most patients. Interestingly, all but one of the hemiplegics showed slower mean velocity with their orthoses on, which reflected a prolongation of the support phase in hemiplegic limb.The parents reported a favourable effect in 17118 patients; the negative one was correctly identified also in the locomotion analysis. It was concluded that the registration yielded valuable, detailed information of the influence of the orthoses, and that the simplified scoring system made the information digestible, but that the lack of standardized norms for this equipment compromised the reliability of the interpretations. References
1 Butler P, Nene A. The biomechanics of fixed ankle foot orthoses and their potential in the management of cerebral palsied children. Physiotherapy1991; 77: 81-88. 2 Hylton N. Postural and functional impact of dynamic AFOs and FOs in a pediatric population. J ProsthetOrthot 1989; 2: 40-53. Hip function in cerebral palsy the kinematic and kinetic effects of psoassurgery C Y Chung, T F Novacheck, J R Gage
Motion Analysis Lab, Gillette Paul, MN, USA
Children’s
Hospital,
St
To evaluate the effects of surgery on the hip in patients with cerebral palsy, this study was undertaken at the Motion Analysis Laboratory at Gillette Children’s Hospital. In particular the changes due to psoas lengthening over the brim of the pelvis were assessed. The study group consisted of 34 subjects (48 sides) that had adequate preoperative and postoperative kinematic and kinetic data available for comparison. In addition, the study group was compared to a control group of 13 patients (14 sides) who underwent a comparable set of surgeries with the exception that no psoas surgery was performed. Each of the patients in both groups underwent multiple other procedures under the same anesthetic. The Vicon Clinical Manager was used to process the data. The preoperative kinematic status of the study and control groups was slightly different consistent with the preoperative decision-making regarding psoas lengthening. The peak (22”) and minimum (13”) anterior pelvic tilt was increased in the study group compared to normal but not in the controls (normal values are 13” and 1 lo, respectively). Hip motion was skewed toward flexion in both groups but to a greater extent in the study group. There was increased peak hip flexion in both groups (43” vs. 42”) at initial contact (normal 35”) and decreased peak hip extension (10” vs. 1” flexion) in preswing (normal 7” extension). Postoperatively, in the study group, all of these values significantly improved toward normal representing an
improvement in their crouch gait pattern. There was no change in the control group. Sagittal plane hip kinetics showed corresponding preoperative deviations in the study group including an increased peak hip extensor moment (0.82 Nm/kg) which occurred later in the gait cycle (13%) than normal (0.48 N&kg @ 4%). The hip moment crossover point from extension to flexion was also delayed to 41% of the gait cycle (normal = 24%). The peak hip flexor moment was similarly decreased (0.59 Nm/kg) and delayed (56%) compared to normals (1.08 Nm/kg @ 52%). Postoperatively, all of these values were significantly improved in both groups but more so in the study group. In addition, the total extensor moment and total flexor moment were improved with psoas surgery. The sagittal plane powers were also abnormal preoperatively in both the control and study groups. The power generation and absorption were diminished in both groups compared to normals. Postoperatively, the Hl generation peak was significantly decreased in the study group (0.12 to 0.05 J/kg) implying less hip flexor dominance. The H2 absorption peak increased (0.03 to 0.05 J/kg), but perhaps most importantly, the H3 hip flexor power generation was not diminished with psoas lengthening. These patients were found to have statistically increased walking velocity with diminished oxygen consumption and oxygen cost revealing overall improvement in their walking function with surgical intervention. This study shows that surgical intervention including psoas lengthening over the brim of the pelvis significantly improves hip kinematics and kinetics in nearly all aspects without sacrificing hip flexor power generation. The quality assessm ent of gait in cerebral palsy I Kelly, A Jenkinson, T O’Brien
Gait Laboratory, The Central Remedial tarf, Dublin 3, Ireland
Clinic, Clon-
Study Objective
To combine the kinematic, functional and cosmetic features of walking, to develop a Quality Score of gait in cerebral palsy. Design
Sixty children with spastic diplegia were randomly selected. All were independently ambulant. Each child was assessed in three ways. A. Sagittal plane kinematic analysis: We used the CODA-3 motion analyzer. B. Functional Walking Assessment: Each child performed eleven tasks of balance and an endurance test and was awarded a functional walking score. C. Cosmetic appearance scoring: A barometer of severity of the cosmetic appearance of walking was developed. Each patient was assessedby eight observers,
measurements before casting (to: -4.8”, t 1: 9.9”, t2: 5.3”, t3: 2.5”). The peak ankle dorsiflexion during mid swing showed an increase (P c 0.001) for all measurements after cast removal as well (to: -10.8”, tl: 4-Y’, t2: 0.9”, t3: -2.9”). We observed an increase (P < 0.001) of ankle dorsiflexion at initial contact (to: -10.6”, tl: 1.8”, t2: -1.9”, t3: -3.2”). When there was a knee hyperextension during stance before casting (minimum knee flexion c 5’) the hyperextension was reduced (P < 0.05) for all measurements after cast removal (to: -5.7’, tl: 6.3”, t2: 0.5”, t3: -1.3’). The cadence was reduced from 145.9 steps/mm before therapy to 133.2 steps/mm six months after cast removal and the walking speed remained unchanged.
279
ward, but the typical gait pattern with an equinus of the foot and flexed knees and hips establishes. On this rationale a new orthosis with a spring function was developed. 10 patients were fitted with these ortheses. Their gait was studied once without any device, then with a conventional rigid type of functional orthosis and with the new spring type of functional orthosis. The results are presented. In summary the conventional orthosis inhibits the dropping of the foot, but leads to a short heel contact and impedes the rocking of the ankle, which is expressed in the force plate data. Walking with the spring type orthosis corrects the functional deformities most efliciously. Kinematics and force plate data are almost normalized.
Discussion
The increase of peak ankle dorsiflexion during stance and midswing results in a greater stability during stance and less problems with foot clearance during swing phase. The increased ankle dorsiflexion at initial contact indicates a better prepositioning of the foot for loading response. All the observed changes lead to the conclusion that short leg casting is a suitable medium-term method to improve the gait and to reduce the dynamic ankle plantarflexion. But with the observed loss of correction after 6 months this method can not be considered a successful long-term treatment. We believe that surgical corrections can be delayed by the use of this conservative treatment until the motor development is more advanced and the results of surgical corrections are more predictable. Moreover, casting is an inexpensive and repeatedly applicable method with only minor risks. Correction of typical gait pattern in spastic bemiplegic and diplegic patients using a functional spring-type orthis
R Brunner, G Me&r, Th Ruepp Motion Analysis Laboratory, Department of Pediatric Orthopaedics of the University of Basle, Children’s Hospital, CH-4005 Base], Switzerland In patients with spastic hemiplegia or diplegia a gait pattern with a functional drop foot is typical. The foot strikes the ground with the tip toes or just the planta pedis in an equinus position. During loading of the leg the body weight forces the heel down to the floor. The spastic triceps reflex is activated. The calf is pulled backwards while the center of gravity of the body moves forward, resulting in an hyperextension of the knee. The force of the triceps acts backwards, leads to a break of the acceleration during walking and is missing at the time when maximal acceleration occurs in normals. The energy for walking increases. These findings are documented by typical force plate- and VICON-data as well as by video-pictures. A way of compensation for the loss of muscle force is early knee and hip flexion. Thereby, the force of the triceps reflex is directed for-
Assessmentof dynamic ortboses with tbe macreflex” locomotion analysis system in children with spastic diplegia and bemiplegia
L van Wendt, S Jiintti, P Tornikoski, R Jaakkola, K Lehtonen Department of Pediatric Neurology, University of Helsinki and Children’s Castle Hospital, Helsinki, Finland Orthoses of numerous types are frequently prescribed for children with cerebral palsy in order to enhance ambulation, but the effects of these have rarely been assessed objectively [ 11. The aim of the present study was to evaluate the usefulness of the Macreflex locomotion analysis system for the registration of the effects of dynamic orthoses. This type of foot-ankle orthosis differs from more traditional ones by being made of flexible polypropylene and by the special supporting and correcting, individually moulded shape of plantar part of the orthosis [2]. The patients were all followed up at Children’s Castle in Helsinki and represented spastic diplegia (11) or hemiplegia (7), were >4 years (mean age 7.4 years), walked independently with or without crutches, and had used a uni- or bilateral dynamic orthosis >6 months. The recordings were made with and without orthoses using a single-camera (infrared), two-dimensional MacReflex equipment with seven reflecting markers attached to the patient. The analysis was confined to nine separate components based on ROM of hip, knee, and ankle joints; gait symmetry, cadence, and mean velocity. A clinically significant change was considered to be present whenever the gait components had changed ~20% and the other components > 5”. A total score was constructed as follows: 1 = improvement, 0 = no change, -1 = deterioration. ReNllts
All but 2 children performed better with their orthoses on, but a very evident favourable effect score (+8 or +9) was shown by only two infants. There was little effect on
280
Gait and Posture 1995; 3: No 4
the movement of the hip, whereas symmetry of gait and the ROM of the knee improved in most patients. Interestingly, all but one of the hemiplegics showed slower mean velocity with their orthoses on, which reflected a prolongation of the support phase in hemiplegic limb.The parents reported a favourable effect in 17118 patients; the negative one was correctly identified also in the locomotion analysis. It was concluded that the registration yielded valuable, detailed information of the influence of the orthoses, and that the simplified scoring system made the information digestible, but that the lack of standardized norms for this equipment compromised the reliability of the interpretations. References
1 Butler P, Nene A. The biomechanics of fixed ankle foot orthoses and their potential in the management of cerebral palsied children. Physiotherapy1991; 77: 81-88. 2 Hylton N. Postural and functional impact of dynamic AFOs and FOs in a pediatric population. J ProsthetOrthot 1989; 2: 40-53. Hip function in cerebral palsy the kinematic and kinetic effects of psoassurgery C Y Chung, T F Novacheck, J R Gage
Motion Analysis Lab, Gillette Paul, MN, USA
Children’s
Hospital,
St
To evaluate the effects of surgery on the hip in patients with cerebral palsy, this study was undertaken at the Motion Analysis Laboratory at Gillette Children’s Hospital. In particular the changes due to psoas lengthening over the brim of the pelvis were assessed. The study group consisted of 34 subjects (48 sides) that had adequate preoperative and postoperative kinematic and kinetic data available for comparison. In addition, the study group was compared to a control group of 13 patients (14 sides) who underwent a comparable set of surgeries with the exception that no psoas surgery was performed. Each of the patients in both groups underwent multiple other procedures under the same anesthetic. The Vicon Clinical Manager was used to process the data. The preoperative kinematic status of the study and control groups was slightly different consistent with the preoperative decision-making regarding psoas lengthening. The peak (22”) and minimum (13”) anterior pelvic tilt was increased in the study group compared to normal but not in the controls (normal values are 13” and 1 lo, respectively). Hip motion was skewed toward flexion in both groups but to a greater extent in the study group. There was increased peak hip flexion in both groups (43” vs. 42”) at initial contact (normal 35”) and decreased peak hip extension (10” vs. 1” flexion) in preswing (normal 7” extension). Postoperatively, in the study group, all of these values significantly improved toward normal representing an
improvement in their crouch gait pattern. There was no change in the control group. Sagittal plane hip kinetics showed corresponding preoperative deviations in the study group including an increased peak hip extensor moment (0.82 Nm/kg) which occurred later in the gait cycle (13%) than normal (0.48 N&kg @ 4%). The hip moment crossover point from extension to flexion was also delayed to 41% of the gait cycle (normal = 24%). The peak hip flexor moment was similarly decreased (0.59 Nm/kg) and delayed (56%) compared to normals (1.08 Nm/kg @ 52%). Postoperatively, all of these values were significantly improved in both groups but more so in the study group. In addition, the total extensor moment and total flexor moment were improved with psoas surgery. The sagittal plane powers were also abnormal preoperatively in both the control and study groups. The power generation and absorption were diminished in both groups compared to normals. Postoperatively, the Hl generation peak was significantly decreased in the study group (0.12 to 0.05 J/kg) implying less hip flexor dominance. The H2 absorption peak increased (0.03 to 0.05 J/kg), but perhaps most importantly, the H3 hip flexor power generation was not diminished with psoas lengthening. These patients were found to have statistically increased walking velocity with diminished oxygen consumption and oxygen cost revealing overall improvement in their walking function with surgical intervention. This study shows that surgical intervention including psoas lengthening over the brim of the pelvis significantly improves hip kinematics and kinetics in nearly all aspects without sacrificing hip flexor power generation. The quality assessm ent of gait in cerebral palsy I Kelly, A Jenkinson, T O’Brien
Gait Laboratory, The Central Remedial tarf, Dublin 3, Ireland
Clinic, Clon-
Study Objective
To combine the kinematic, functional and cosmetic features of walking, to develop a Quality Score of gait in cerebral palsy. Design
Sixty children with spastic diplegia were randomly selected. All were independently ambulant. Each child was assessed in three ways. A. Sagittal plane kinematic analysis: We used the CODA-3 motion analyzer. B. Functional Walking Assessment: Each child performed eleven tasks of balance and an endurance test and was awarded a functional walking score. C. Cosmetic appearance scoring: A barometer of severity of the cosmetic appearance of walking was developed. Each patient was assessedby eight observers,